Provider Demographics
NPI:1740294412
Name:RICKS, CHARLES SHUBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:SHUBERT
Last Name:RICKS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 S ASPEN CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-5175
Mailing Address - Country:US
Mailing Address - Phone:559-625-9300
Mailing Address - Fax:559-625-9330
Practice Address - Street 1:136 S ASPEN CT
Practice Address - Street 2:SUITE B
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-5175
Practice Address - Country:US
Practice Address - Phone:559-625-9300
Practice Address - Fax:559-625-9330
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23135122300000X
CAGA13581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93774-01OtherDENT-CAL